Spotlight on Collaboration

Case management for a geriatric outreach program in British Columbia
by Marnie Lamb

Angela Hardie is the occupational therapist and one of four case managers for the Geriatric Outreach Program on Vancouver's North Shore. She works with a diverse team that includes a pharmacist, a dietician, a nurse, a physiotherapist, a recreational therapist, a social worker and a geriatrician (a physician specializing in caring for the elderly). Having the resources of so many other health professionals has made this a �dream job for an occupational therapist,� Angela enthuses.

The Geriatric Outreach Program is a short-term, intensive service that provides assessment and treatment for frail older adults with complex conditions. These individuals have difficulty living in the community or have been recently discharged from the hospital and are considered high risk for readmission. Clients can be referred to the program in various ways, including self-referral, but must have the permission of their family doctor to participate.

For clients with functional problems, either Angela or the team's physiotherapist acts as case manager. Although she performs the usual occupational therapy tasks such as home safety and risk assessments, Angela believes that a case manager must look �beyond just the traditional occupational therapy� to �oversee all the [client's] problems.�

The group thus operates as a team to provide assistance to one another in dealing with clients. Some clients are overwhelmed at the idea of interacting with too many of the team members and prefer to deal with only one person, so the case manager is often called on to perform tasks outside his specialty. For example, Angela may identify a nutritional concern while doing a kitchen assessment and thus consult the dietician. Likewise, if the social worker/case manager sees a need for a device to help a certain client hear the doorbell, she asks Angela for advice. However, should a major issue outside her specialty arise, Angela will ask other team members to visit the client in question and address the issue.

The program's prime goal is to keep clients in their homes. Avoiding hospitalization has both economic and psychosocial benefits. Fewer hospitalizations and lower health care costs go hand in hand. Angela believes that most clients �can function better in their home environment,� even those with dementia, who make up a portion of her clients.

Clients with dementia present a particular challenge. Lacking insight into their own needs, suffering from memory problems and often insisting that they are fine, these clients are sometimes reluctant to accept home care services. Angela notes that the team works particularly well in such cases. For example, a client with dementia will often forget to take pills or eat. Angela would assess the client's cognitive function and his ability to take medications and prepare nutritious meals and snacks. The pharmacist and nutritionist would assist in simplifying his medications and meal plans, and all three would work together to encourage the client to accept additional home help if needed. Together, these different types of interventions improve the client's quality of life: if a client is taking the proper medication and eating a proper diet, he may show an improvement in his general health, mobility and function. The program does see numerous clients with dementia in the early stages, but clients with major dementia, depression or behavioural problems will be referred to the Geriatric Mental Health Team.

Angela admits that one of the downfalls of the program is its length. The program was set up as a short-term intervention, with the average length of participation being three months. For many frail, older adults, the program can help to stabilize their health and improve their function, but some may need ongoing close monitoring to keep them healthy and functional in the community. According to Angela, there is a gap in long-term resources for frail older adults with complex medical conditions. The role of the enhanced case manager, a long-term care case coordinator who would carry a smaller caseload, has been recommended but not yet funded. In the meantime, Angela and the other case managers do their best to keep clients out of the hospital and in their own homes.

-This article originally appeared in the September/October 2003 Edition of �Occupational Therapy Now�.